Provider Demographics
NPI:1619034287
Name:AMBULATORY MEDICAL CLINICS PLLC
Entity Type:Organization
Organization Name:AMBULATORY MEDICAL CLINICS PLLC
Other - Org Name:OAKWOOD SOUTHSHORE GROSSE ILE URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT SHARED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-3326
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:COMPLIANCE
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1964
Mailing Address - Fax:
Practice Address - Street 1:8944 MACOMB ST
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-2089
Practice Address - Country:US
Practice Address - Phone:734-542-6100
Practice Address - Fax:734-542-6102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063833207Q00000X
MI4301082093207Q00000X
MI43010801608207Q00000X
MI4301065784207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG74646Medicare UPIN